The URL can be used to link to this page

Home My WebLink AboutBLD-23-002785 ; � CIU ki It I ) O ni 2_ Office Use Only / �''YA `� .:4. p i/ G'123 Permit'. Y. 1t �'�``.]ty��{.'y,�`}� -�h,/-,' Amount /g0. 60 ,\ ATTA-C*5E'`. f; ° qg• 60 7i`. y Permit expires 180 days from y �y 6-�� issue date (� (1D—A 16001-78 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth. MA 02664 NOV 17 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 4#1af1+jC Atit - By: ASSESSOR'S INFORMATION: l Map: 71 Parcel: 3 OWNER: t r 0In �� / 1 1'/—0v — q ill' NAME PRESENT ADDRESS r� TEL, # ?ONTRACTOR: 6-cesk.) ,)Dok-`la Cor ` iO 14f 1 c4,f'1.. t S.Vetio ei fin NAME MAILING ADDRESS TEL.# — 0 Residential ommerciai Est.Cost of Construction$ ��*"'' 66 6 Home Improvement Contractor Lie.# I 99(00 t Construction Supervisor Lic.# ‘ 5 -11 0(r/r 'Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 1E14ave Worker's Compensation Insurance l l Insurance Company Name: it0 Ii.ek �„ es l M -TA 5 Worker's Comp.Policy# 'W(C 5156—lba 1 qw .-)0 - WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing* (max.2 layers) Insulation I I riOld Kings Highway/Historic Dist. Ill Replacing like for like Pool fencing ri -�, tum p *The debris will be disposed of at: Yarn (/l/ Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and fs 4j ecution under M.G.L.Ch.268,Section 1. i Applicant's Signature: _ — Date: t 1 (I-1 /02°L Owners Signature(or attachment) illi'—� Date: /if—17 e�' Approved By: Date: /// 1 3uildinp,Official( desio EMAIL ADDR PA. l Zoning District: I Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: • Yes No Yes No Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards.• • ConsOrtt'lit tfSpArvisor . CS-110491 ! OLpires:09/27/2022 BENJAMIN GREW , ; 4 20 ATLANTICAVE �t / SOUTH YARMOUTH' 84 -1 • sp Commissioner �a (JOV7l/7ld/l• er7iiid•l/..&l7,ze it/-Jea) .. ;•, Office of Consumer Affairs&Business Regulation ;HOME IMPROVEMENT CONTRACTOR TYPE:individual • Registration Expiration • 1.99607 09/15/2022 BENJAMIN GREW BENJAMN GREW 20 ATLANTIC AVE` SOUTH YARMOUTH,MA''02864 Undersecretary 11/17/22,9:24 AM Details Licensee Details Demographic Information Full Name: BENJAMIN GREW Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: United States License Information License No: CS-110491 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 10/24/2022 Issue Date: 1/6/2017 Expiration Date: 9/27/2024 License Status: Active Today's Date: 11/17/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents https://madpl.mylicense.comNerification/Detai ls.aspx?result=6b8b 1226-800e-41 af-90a4-15bdd6d7ec24 1/1 i- i, 1: ass. ov ( 4%,„,e t 4.70 ro #1r, ..; i,„.t ! P te'4' l' r''''''. 1 r":4-'*'* , 4' '' /4444 '11 I /°‘ I 7 4:„.1 CA I 1 CA I.- 4 %). ,c) %,•w' HIC Registration Complaints Registration 199607 Registrant Benjamin Grew Name Benjamin Grew Address 20 Atlantic Ave City, State South Yarmouth, MA 02664 Zip Expiration 09/15/2024 Date Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search . The Commonwealth of Massachusetts ' +., 1 Department of Industrial Accidents VIF 1 Congress Street, Suite 100 Boston, MA 02114-2017 r,Sv�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): C r&I,J gui'l /r/7G; (6. Address: ,96 )/Cy1 F/Z A ' City/State/Zip: 5. (T aL,f7i kt- Eg Phone #: .5z,9 3cly 62, Are you a mployer?Check he appropriate box: Type of project(required): l. I am a employer with ( employees(full and/or part-time).* 7. E New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. (modeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4,1DI am a homeowner and will be hiring contractors to conduct all wcrk on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees, 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.uisurance.t 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Nb9 t Policy#or Self-ins.Lie.#: a.,` Q `fO (i ;,`_~ G,12 - Expiration Date: y�.7r� ,;�_, Job Site Address: ) / 4`0A LAV-t— City/State/Zip: O, c't /14 Pee y Attach a copy of the workers' compensation policy declaration page(showing the policy nutber and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a penalties of perjury that the information provided above is true and correct Signature: Date: it h -vda,.. Phone#: S 3 Cf y r 3 c) Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# — Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: